Everything You Need to Know About Therapy

Hello and welcome to Being Well. I'm Forrest Hansen. If you're new to the podcast, thanks for listening today. And if you've listened before, welcome back. We talk about therapy all the time on the podcast and allude to all of these different kinds of therapeutic approaches. But it's been years since we actually did a focused episode on getting the most out of therapy. So today we're going to be exploring the many different approaches.

how to know if a particular therapist is right for you, and what you need to know to get everything you can out of this process. For some people, that's going to mean working with a clinical psychologist. For others, it might mean working with a therapist, a counselor, or a coach. And for many,

And mind me just listening to a podcast like this one, which is great too. I'm really looking forward to talking about all of this today. And my guest for this episode is, as usual, Dr. Rick Hansen, who has been doing this for over 35 years, has had hundreds of people walking. to his office. How are you doing today, Dad? I'm thoroughly psyched for this conversation. And in your categories of people who can have therapeutic conversations with others,

We'd like to add psychiatrists and sometimes physicians in general. I'm looking forward to both attending to... the more orthodox frame of people with a license as a therapist, as well as broadening it out to a larger consideration of what helps interactions be therapeutic. And in particular, what helps what we do inside our own being, inside our own minds, to have therapeutic benefits for us? I just want to start by asking you, based on all of the time that you've worked with people,

What do you think are some of the biggest factors that lead to a course of therapy inside of that frame? Maybe these other frames that you're speaking to as well, but particularly a course of therapy going really well for somebody. There's been a lot of research about this. I'll refer somewhat to that research and also to my me-search, my own experience with people. First off, I want to definitely name the issue that the person brings matters.

If a person is walking in the door with complex PTSD based on multiple traumatic experiences, often when developmentally they were most vulnerable, we've got a lot of stuff to do, okay? Or if someone is coming in with a longstanding kind of biologically rooted issue like schizophrenia or bipolar disorder, then, you know, we have a lot.

more to do. And it can take longer to have a result. So the severity of the injury, the depth and the biological rootedness of the pathology make a difference. That shapes outcome. And we need to be realistic about how long it takes. Second, the circumstances of a person.

If a person is still in the situations that are distressing and disturbing them and wearing hard on them every day, and then they go see their therapist or coach for an hour a week, but then they're back in the battlefield or the war zone yet again.

again, well, that's also going to constrain results. If they have family members who are constantly raining on their parade, why are you seeing a therapist? Aren't you over that yet? Blah, blah. You know, that's going to get in the way as well. Flip the other way. If their circumstances are supportive and friendly, then they're going to tend to get more out of what they're doing. All that said, now internally, that's where we're really focusing here. Number one, motivation of client.

A great therapist cannot overcome an unmotivated client. A motivated client can get the most out of even a mediocre therapist. So motivation of the client. That includes what they do and the other 167 hours in the week between that one hour in the week that they go see their therapist. Yeah. Motivation.

Absolutely. It's kind of like if the key to success in real estate is three things, location, location, location. I think the key to success in the therapeutic journey for a client is three things, motivation, motivation, motivation. That said, second major factor, and it's a little delicate to talk about it, it's the overall, I'll call it beingness, level of functioning of the therapist.

Is the therapist themselves someone who's done a lot of inner work, who has a lot of access to their interior? Is this someone who has engaged their own mind in deep and productive ways so they can... help their clients, engage their own minds in deep and productive ways. That's what you're really looking for there.

And it almost sounds a little elitist to talk about it, but it does speak to the importance of who the therapist is as a person, right? We don't tend to care too much about who our surgeon is as a person. We want someone who's hyper-competent with the scalpel and what they do. But the therapeutic process is person-to-person, being-to-being. Psychotherapy is core-to-core. So you want to be with a therapist.

who can engage with you in that deep way. So level of functioning of the therapist. Then two other factors, one of which is familiar in research, on the basis then of the motivation of the client and the depth of being of the therapist. there's the possibility of a positive, strong therapeutic alliance. A strong relationship between client and therapist is certainly a great predictor of results.

And then last, there's another factor that I really want to name here. It's often one that gets left out, and I'm kind of shaking my head about that fact. Actually engaging the deeper... more specific mental processes in the client, which are often emotional and somatic and really getting down to that level with what...

is shifting and what is it actually like to be the client and especially what is shifting inside in lasting ways. You know, very often therapy and therapeutic conversations are superficial. frankly. They kind of float around the edges of things, and they don't actually get down to the underlying process of change in the client.

And then the client, you know, may have the nice experience of being with a person who's genuinely caring and has unconditional positive regard for them and is a good listener. That's great in and of itself. But so much therapy. that is only mediocre or even not helpful at all. It's because the therapist and the client did not get down to that deeper layer where lasting change occurs.

That's what you're trying to do in therapy, good change that lasts. And so if you're not actually engaging the change process deep in the basement of the mind, then there won't be much lasting change. And so I think that's a major factor as well. Are you really getting at what matters in a way that moves things forward in enduring ways? In that list that you gave me, which I thought was a fantastic list, circumstances,

Level of functioning of the therapist, motivation of the client, the alliance between the two of them. Are you really engaging those underlying processes? Notably, you didn't mention the modality of therapy that's used. And so I want to give you an opportunity here to talk about that a little bit. Before we do that, if I could just say one little teeny thing. Even if a therapy is doing something that might seem at first more surfacy, like cognitive therapy that's addressing certain beliefs.

The change process itself can be very deep, right? So let's suppose, I speak in my own case, a person, you know, as an adult has the belief that they're basically a wimp, kind of a weak, you know. somewhat shameful kind of person, which was a belief I carried into my adulthood from my childhood as a very young kid going through school. And then there's this counter-belief. No, I was not a wimp. I was a nerd.

And actually, in my own way, I'm a pretty feisty, determined, potentially quite forceful person, as Forrest knows from personal experience. That's a counter-belief. Okay, so now we're doing cognitive therapy, right? Classic cognitive therapy stuff, and we're trying to dispute the pathogenic belief with the counter-beliefs grade. Here's the thing. What are you doing inside your mind?

to help yourself develop conviction in this new belief. You know, what happens deep down inside you as the new belief gradually dislodges the old belief? And how can you help the new belief actually replace the old belief? What's happening with parts of you that are holding onto the old belief? That is a deep process. So even if- Great point.

Yeah, the type of therapy might seem more heady, et cetera. The change process itself, it's specific and detailed and deep in us. And I think a lot of therapies don't engage it. Great point here. To speak to... a little bit of the why you might not have named a particular kind of therapy as being the good therapy and other kinds of therapy as being the not-so-good therapy. The general broad finding in the research is that most of what I will call

somewhat reasonable approaches to therapy. These are somewhat science-based. There is some kind of framework that exists behind them that you could view as fairly credible, however you want to parse that language. Most of these approaches to therapy are roughly as effective as each other. Now, there might be particular approaches to therapy that are really good for specific kinds of problems.

But broadly, across a range of problems, you're not really going to find one approach to therapy that is particularly good for all people. What I would kind of argue here is that a factor in this that can be very relevant for people is the fit between them, between their nature, and the kind of approach to therapy that is used. So this is a much more individual part of the process.

than making just a sweeping generalization about this therapy good, that therapy bad. I think that's really well said. And I also want to emphasize new research that shows that in the therapeutic process, much as in other domains of skillful activity, that feedback is really useful within fairly short timeframes. with the proviso that people act upon the feedback. Therapists who for example have the client fill out a little form.

you know, every other session. How's it going? Are you getting what you want? What progress are we making with the particular issues? What was helpful, let's say, in our last session? What was not so helpful? That then... creates a feedback process that can actually also be a major factor in the in a therapy having an upward spiral to it getting better and better for the client totally right on and there are even some approaches to therapy or maybe

I should say some specific clinicians who really incorporate that kind of a process into the therapeutic process itself because you think about the nature. of being in what can feel like a low power position. A client in therapy, you're working with this big powerful clinician, you feel kind of small and more vulnerable inside of that role sometimes for people. And the nature of offering feedback

feedback from that position can be kind of fraught for people, particularly people who have not had that experience a lot in their life. I want to go back to your point, which I think is so great, about the fit, right? And it's kind of like everything. You know, teachers can be great with a certain style, you know.

One teacher might be kind of formal, classically trained and lecture-oriented. A different teacher might be, let's all get in the mud puddle, kid, and learn about science that way from the ground up. That style of teacher, they're both equally good.

But certain students are going to do better with one kind of teacher, let's say, than the other kind of teacher. There are just so many people who I'm thinking of Elizabeth's experience as more of a somatic therapist who have worked with Elizabeth and given her feedback along the lines of, wow, I just thought that therapy wasn't for me.

And it was because I'd only done kind of these very top-down cognitive processes in the past, and then I work with somebody like you who has such a different approach, and wow, I'm getting all of this value out of it. And I think that's just true for a lot of people when they finally find the thing that actually works for them.

That's exactly right. I think that's a very good example of a certain type of person. The person who walks in the door, and they could write basically a book about their personality, but it hasn't made any change. So more cognitive approaches. aren't going to make much difference. They need to do things that are much more experiential. Flip the other way, I've worked with people who have done a fair amount of personal growth of things, I would say for sure, that are somatically oriented.

And their belief systems and their mind is very disorganized and cluttered with a lot of beliefs about things that are true that are just really not true. creating more clarity in their outlook and in their perspective through more cognitive means is a particularly good fit for that type of person at that time.

So next, I think it probably makes sense for us to talk a little bit here about some of those many approaches to therapy that exist. This can give people a sense of what might be possible for them, what's out there that maybe they're not as familiar with or hadn't heard of yet.

And along the way, we'll probably talk a bit about what makes for a good match between the therapist and the client, some of the questions that you can ask your therapist if you're interested in identifying some different therapist green flags and red flags. We're going to talk. about all of that stuff. But before we do, I want to give a little disclaimer here about the number one question and comment we get every single time that we talk about therapy on the show. And it's, wow.

Therapy is real expensive, and my limitation here is actually not finding a good therapist or finding one who's available or finding one who has a modality that works for me. It's paying for the dark thing. And I wish that I could give people a great solution to that problem. Unfortunately, access issues are probably the number one issue in the field right now, I would personally argue.

And the problems here get to a lot of issues, particularly in the United States, with how we do medical insurance. and how therapists become compensated by insurance companies for the work that they do. So this leads to a situation where many therapists do not take insurance. In order to get to a place where you are offering therapy in the United States,

You've often gone through a six to eight year process where you have made little to no money while accruing an enormous amount of debt. So that's on the one hand. on the other hand you have insurance companies which have tables of compensation for different kinds of medical fields. In other words, there is a number that they pay a therapist per hour if they work in a given state for the time that they spend working with the client who is insured by that insurance company.

Often that number is half to a third to a quarter of what that therapist can earn on the open market. So you've got a therapist who has accumulated $100,000, $200,000, a quarter of a million dollars of debt, of academic debt, by the time that they pop out of this process. And they're given the option. They can either chase down an insurance company to try to get the $50, $80, $100, depends on what state you work in, from them.

and often have to go through the absolute rigor to get these insurance companies to actually compensate them for the time that they have spent with the clients. Or they can enter the open market and charge $150 an hour for their services. without having to deal with any of that. And that's why we are where we are, essentially. That is the bottom line. The issue is fundamentally the problems with insurance companies in the United States.

And if insurance companies compensated therapists at a more appropriate open market rate, what you would see is many more therapists work with insurance. Therapists want to offer accessible coverage to people. They want to help people. This is an artificial problem created by the greed of a very small number of people. And fortunately, there are some options that exist that maybe we can talk about in a little bit more detail here, Dad. But I wanted to just kind of give that...

give that context and give that little monologue out of my own frustration with this whole issue. I'm so glad you said all that. It's completely true. From a practical standpoint, it underlines... the pragmatic usefulness of people getting the therapeutic benefits they can through other means, doing courses, doing audio programs. listening to meditations from sounds true or inside time yeah calm or listening to a podcast like this one hey yeah exactly right and

Even doing things that are known traditionally to be potentially therapeutic, you know, sitting by the beach, looking up at the sky, journaling, going for a long walk. You know, these are good things to do. Also, if you're going to come into seeing a therapist, come into it prepared. You know, having done, you know, some significant inner work. There are wonderful workbooks that are available for people of many different kinds.

that can be done. So we can do these things. I'm not saying these things to justify the capitalistic insurance reimbursement system. I'm not. I'm just saying, well, given so much that's not good. What can you do on your own to help yourself? I've done a lot. I've changed a lot over the years. And I've had many therapeutic experiences that did not occur by talking with the therapist. Yeah, totally.

To give just a couple of options for people here that you might not be familiar with, for starters, many therapists do offer sliding scale pricing, or they reserve a certain number of slots inside of their practice for people who…

have more pressures on their income, and who might not be able to afford their full rate. So that is an option that does exist for many people. Another option that you might want to think about is there are many... clinics and more community-focused services that exist out there. that often offer lower fee services to people. So that might be an option. Another one that people might not be familiar with is that it is often cheaper to work with a therapist who is currently in their associateship.

Now you need to understand what's happening then. You are essentially working with a trainee inside of the way that we think about it. But often this is a trainee who has a thousand, two thousand hours of clinical experience. This is not somebody who took their first Intro to Psych course in their undergraduate program. These are very, very credible people a lot of the time. They just haven't completed all of the formal requirements.

So I just want to toss those all out there as possibilities for people that might open up access a little bit. Is there anything you'd like to add here, Dad? I would rather receive therapy from a talented intern than a jaded... Not very deep therapist with 20 years of licensure. For sure. Same. Same. Totally. Yeah. Well, that is unfortunately a topic that we could spend several episodes talking about.

and mostly just shake our heads the whole time. So out of a desire to move to something that's a little bit more fun to talk about, let's start exploring some of those various schools of therapy that we were talking about a little bit earlier. According to a Psychotherapy Networker article from 2020, there are over 250 distinct schools of therapy. So we're going to be doing a lot of generalizing here. I would break these into five...

major, major, major schools of therapy with a lot of other approaches to therapy that we're just not going to have the time and space to talk about during this episode. I also want to emphasize that we're talking here about the Western psychological tradition.

This is what Rick practices inside of. It's what I'm most familiar with. There are a lot of options out there that do not fall under this particular tradition, but it's what we're focusing on here. Probably the best place to start is with psychodynamic therapy. which is widely considered the precursor, the original approach back in the 1900s-ish.

to modern Western approaches to therapy. This is Freud and Jung. It really focuses on the investigation of the unconscious mind, the ways in which the desires and impulses of the unconscious mind come through in our conscious behavior, and various techniques that can allow us

to bring unconscious material into the conscious and then process it in all of these useful ways. I don't know if you want to throw anything else out here about psychodynamic therapy, Dad, because I know that you have a bit of an affinity for it. Grounded in psychodynamic therapy is a developmental model that things happen when we're young and they have effects.

A child is a very different kind of creature, a different kind of being with a very developing mind. So there's an attention to that that's really important. Psychoanalysis also really includes the murky depths, the weird stuff, you know, down in there. It's just, oh yeah, bring it on. It's grist for the mill. It also emphasizes conflict.

inner conflict. You know, the part of you that wants to do this, the part of you that wants to do that, including conflicts between immediate gratification desires and a sense of conscience or a sense of superego regulation of yourself. And so these are very, very fundamental ideas that are quite employed in other therapies as well. Last, I'll just mention the notion of defenses.

that people defend against experiencing things that are scary, the dreaded experience, for example. And some of those defensive operations appear during the therapeutic process itself. So paying attention to defenses as well is something that came out of psychoanalysis. Yeah, because the psychoanalytic approach is kind of the OG Western approach to therapy, you will see a flavor of it or an idea of it integrated into a whole bunch of different approaches.

Another school that you could maybe set up as kind of the foil to psychoanalysis in some ways is the School of Behavioral Therapy, which focuses more on modifying observable behaviors through techniques like reinforcement, punishment.

Operant conditioning is a phrase that came out of behavioral approaches to therapy. This popped up more in the 1920s, 1930s. And behavioral approaches are another one that are really woven in to many, many other... approaches to therapy because where the rubber beats the road for many people is what are they actually doing out in the world and that's what behaviorism is trying to control for yeah so much of the recent focus on atomic habits

You know, the power of habit. Oh, yeah, yeah. Very much draws on. Very behavioral. Yeah, operant conditioning and reinforcement and so forth. One of the things I'll just mention that really stands out. in behaviorism that I've given a lot of thought to is the power of variable reinforcement. Pull the slot machine. Yeah. Yeah. So that slot machine is set up. Let's suppose that it pays off one time on average.

in a hundred polls. The problem is you don't know when the next one will be. It's not like... it pays off, and then 100 times later, it pays off, and then 100 pulls. After that, it pays off. It could pay off at any point. It's over a long run that it averages 1 in 100, and that really tends to keep people keep pulling. flips the other way. If a pain could be delivered, if a punishment could be delivered variably, that too can make people very scared. Think about in relationships.

If the odds of a bad interaction with an authority figure rooted in your background as a kid is that, well, about every 20 interactions were really crummy from your point of view.

but you never knew when it was coming next, that can really foster a generalized freeze response that in the face of... the future you're freezing in the face of the future because you never know when the next punishment is going to come your way so that to me has been very useful in thinking about how we get shaped by things

being careful about variable reinforcement in how we treat people and realizing that over time, we need to look for counter experiences to get out of the trap of that variable reinforcement. That's a great point. And I also love here, Dad, how you're throwing in kind of a lesson from each of these approaches to therapy as we go kind of naturalistically. So let's keep that going here. The third one that I would mention is humanistic approaches to psychology.

This came about more in… My favorite, I'll confess that. Yes, probably your favorite approach. This more came about in the 1950s, Carl Rogers. was a major figure in it. It focuses more on facilitating self-discovery, personal growth, and even self-actualization by trying to figure out what the client really cares about. And it often focuses more on the relationship.

between the client and the clinician. And one of the roots of humanistic approaches is the fundamental view that everyone is a good person with a lot of potential. And if you're just given the right space and the right opportunity, that potential will have the environment it needs to reveal itself in various ways. I love humanistic psychology. It's very affirming. And you can see the trajectory here.

We start out with Freud, who is absolutely groundbreaking, whose famous initial book was On the Interpretation of Dreams. Yeah, 1900, if I'm remembering right. Yeah. that the inner life matters, and there are reasons why people are what they are. And he came up during the Victorian era, so just his... talking about the role of sexuality, including sexual eroticized experiences, even in childhood. It was quite scandalous at the time. Then you see the pendulum swinging into behaviorism.

oh, you just need to change the schedules and we're going to get those pigeons, oh, I mean those humans, to do what we want them to do, right? And run those rats down the proper mazes. And then you see the counter to that. So we've got, of course, Hegel here with thesis, antithesis, and synthesis. Yay, dialectical materialism coming here. The swinging back and forth. Now we have humanistic psychology that says forget.

Pigeons. Humans are really complicated. They're naturally good. What we're trying to do is to release the natural goodness in them. I'll just name here, since you've nudged me to do a takeaway. It's been only really recently. That I've come to appreciate the value of recognizing yourself as a globally good person. A basically good person. Yeah. And in ways that are probably routine.

to see in other people and to recognize and categorize other people as, okay, Forrest is a basically good person, but to... Say that for myself. Whoa, that's a big deal. And yet if you do, if you really help yourself rest in the sense of your fundamental decency, your fundamental kindness, your good intentions, your basic goodness.

Paradoxically, it makes you a lot more able to deal with your bad habits and your bad intentions and the creepier underbelly in everyone's personality. You're a basically good person. to say that and to feel it it's challenging it's a taboo but boy is it good for us okay yeah i think that's great maybe a little

Pendulum swing, even humanistic psychology. Cognitive therapy is the next one that we should probably talk about here. Yeah, there was all this heart-centered humanistic stuff. Then we needed to go to the head. Yeah, exactly right. And this is often combined with other forms of behavioral approach, and that gets us to CBT, which is cognitive behavioral therapy, which is probably, I would say these days, the kind of...

I don't even know what the right language is here. I don't want to say like dominant approach or gold standard approach, but it's definitely like the most commonly taught approach I think is probably accurate to therapy in the United States at least. And there's a dirty little secret about that related to...

Why therapy costs what it costs. Do you want to go into that a little bit, Dad? Or do you want me to... No, I'll just leave it. No, I better say something. So cognitive behavioral therapy is good. I use it. I do it. I've gotten benefit from it. That said... Number one, it's probably the easiest form of therapy to study because it can be manualized and procedurized. Eight-week course, yeah. Yeah, or just have people fill out the workbooks.

you know, and so forth. So therefore, you know, it's in that category where if just because we can measure it doesn't mean it's the most important thing, right? So point one. Point two. it lends itself naturally to very short, finite, bounded courses of treatment, which insurance companies love. Love. Yeah. They want the one session or the six session structure. And so in part because of the medicalization.

of psychotherapy, and I'll speak to that in a second, and then the insurance framing of it, that has tended to drive people in that more cognitive behavioral direction. More broadly, I also want to add that therapy... has been brought into a medical model. Now, people like the humanistic psychologists tried to take it out of the medical model. And there's been a strong tension.

in the field between a medicalized model and a more existential, soulful, exploratory, creative- Warm and fuzzy, some might say. Yeah, warm and fuzzy kind of approach. Yeah. Coaching, by its nature, steps out of the medical model because coaching is not framed as a treatment for a medical disorder, a psychiatric, psychological disorder.

So it doesn't focus in that way, although coaching approaches can be very helpful for things that could be categorized, like chronic anxiety, say. My own feeling is that net, net, net, certain... disorders really do fall into a medical model well. They really do. There's a problem there. We're diagnosing it. We're treating it. Moving on. But on the other hand, so much of what people care about...

trying to make a tough decision related to raising your child or whether to stay in a marriage or leave. These do not fit into neat medical categories. And trying to shove these complex, murky, multi-level, very... profound issues for people into a medicalized pathology to get insurance coverage and reimbursement for that particular treatment, you know, really does a disservice to the breadth and profundity of what the person is grappling with.

So I think it's been unfortunate, frankly, that psychotherapy has become so medicalized. Yeah, I totally hear what you're saying here, Dad. And one of the things that I think is a little complicated when talking about CBT is that CBT is in this...

This position of having been kind of forced into that framework in a lot of different ways for the reasons that you're describing, including like insurance company compensation. But the fundamental ideas or practices or techniques of CBT that you're exploring.

are these incredibly rich practices. Like it's been gold standardized because it's really, really good. And it's particularly really, really good at dealing with certain families of problems. So what CBT focuses on in particular is identifying and changing.

different kinds of negative thought patterns. This is what you were talking about way back at the beginning of the conversation, Dad, with that stinking thinking as it's sometimes referred to in certain settings. So these are the beliefs that we have that contribute to different kinds of emotional distress.

And so you can see just how broad that idea is. There are so many beliefs a person might have that could contribute to them feeling really bad about something or having a really hard time stepping into a new phase of their life or a belief about themselves that...

you know, whenever we talk about limiting beliefs, we're in the world of cognitive therapy a lot of the time. Cognitive therapy-based approaches came around more in like the 1960s, if I'm remembering correctly. Again, a bit of a response to the humanistic movement. And Aaron Beck is kind of widely regarded as one of the founders of cognitive-based approaches. And then narrative therapies. We talked about that recently, how to change this story.

that you tell yourself or you tell other people about your life. That is a kind of a cognitive kind of sort of approach because it's, you know, engages language. how, you know, and like I said, narrative and storytelling. So we want to kind of call it out, although it overlaps with some other stuff too.

Yeah, totally. So we've talked a little bit already about some of the usefulness of this kind of a process. We've spent a little bit of time here with cognitive therapy, but do you want to throw anything else in at the end that you think is a particularly good lesson from this approach? What you believe matters. Yeah, that's the big takeaway for sure. That's great. I'm glad you asked me that, Forrest. Perspective or meaning is also...

a lot in what we call cognitive therapy. So what's your overall perspective about something, your framing of it, and what's the meaning of different events? Like meaning-making is really central here. So that's kind of really, really helpful. So I think that's true. And then what really interests me a lot is how you develop conviction for what's really good for you. How do you attach to that new belief? Yeah, totally. Yeah, how do you help it sink in? How do you surrender to it?

And increasingly, how does that new outlook really sink down inside you? So it's where you come from increasingly. You can fill out those checklists forever. You can write down these counter-beliefs forever, but if you don't really believe them, and here's the other thing, here's the other thing that really shows up in cognitive therapy, which is, what do you want to win? You've got these two people.

These two voices, right? You know, critical, you suck, you're horrible, negative belief, blam, blam, blam. And then you have the counter to it, right? Ricky's a good person, fundamentally, right? Who do you want to win? And very often, people ally with that negative critical.

voice. Sometimes they're afraid of what might happen if they don't ally to it because then their world would fall apart. Plus it's a familiar voice. So here too, with cognitive therapy, you have to ask yourself, which team do you want to win? That's a very important aspect too. Awesome.

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And these were responses to what were perceived as limitations with the CBT model. And they incorporated more mindfulness and also acceptance-based techniques into that traditional CBT approach. So this includes a whole bunch of different approaches. DBT, mindfulness-based cognitive therapy, compassion-focused therapy, that's CFT, schema therapy, and I'm sure a bunch of other approaches that did not pop up when I was doing the research for this.

This was more than 1980s for ACT with Stephen Hayes and DBT with Marsha Linehan. And these are really phenomenal approaches. We talk about them a lot on the podcast because they have a little bit more of that mindfulness basis, which is such a big part of what you do, Dad. I think there's a lot of ways in which these wonderful evolutions, starting initially with psychodynamic approaches and then behaviorism, humanistic approaches, cognitive approaches, mindfulness-centered approaches.

in some ways are grounded on a false critique of what they're growing out of, right? And so the mindfulness-centered approaches were centered in a critique of... You know, clients making deliberate efforts to change their own minds, really notably, let's say, through CBT methods. as a dualistic or performance oriented and people were failing at it. And that sense of failure was just reinforcing the problem that came into therapy to fix, right? But in fact, it's possible to do both.

It's possible to be making deliberate efforts inside your mind with your thoughts, with your behaviors, with your overall outlook, while also making those efforts in a larger context of acceptance. of yourself as you are so far, a larger context of allowing feelings to arise and pass away, the two together. So I think of those as a combination of being with and working with.

If CBT is very much an exemplar of working with your mind and mindfulness approaches are more an exemplar of being with your mind, the two are really necessary. And I think that's one of the hallmarks of effective therapy. It's like a bird needs two wings to fly. We need to both be with what we're feeling and what it's like to be us and also work with it using wise effort to nudge it to a better place over time.

We talk about the benefits of mindfulness-based approaches on the podcast essentially every episode. So I'm not going to really nudge you here, Dad, to talk about a major takeaway from this. But if you have just a really quick one, maybe we can toss it in here. I would say, is that very often we experience pain. We feel sad, we're scared, we're angry, we feel ashamed, and then we resist that experience.

We push against it. We blame ourselves for having it. We blame others that we still have it. And those second darts that we throw ourselves at the primary experience that we're having. actually become a lot of the problem. Sometimes our solutions, we try to solve the problem of pain by overeating, over drinking, over yelling. But the mindfulness approaches I've been really great at.

is teaching people how to be with what they're feeling without initiating those secondary reactions that actually create a lot more trouble for them. For example, around depression. Mindfulness-based cognitive therapy for depression to prevent relapse has been shown to be very effective. And one of the things it does is it helps people to reframe.

Now, that's a cognitive approach to change your perspective. What's the frame in which you hold something? To reframe depressive feelings as impermanent, transient, occurring. due to causes and conditions, and as those causes and conditions change, so will the experience. If then they are able to simply be mindful of a depressive feeling that arises without getting panicky about it, then...

very often that depressive feeling will arise, but it won't be able to sink in. The key issue with depression often is to prevent relapse. That's the key. Once you get a person out of an episode, you want to prevent recurrence. And these mindfulness approaches are really good in that regard. They also are very good for people who are performance oriented. And so they tend to really beat themselves up around performance, including in the therapy.

And one of the very nice things about these mindfulness approaches is it's hard to fail them. So those are the five major, major schools of therapy. underneath which are all of these many different approaches that have sprung out of them in different kinds of ways. But I do want to give a shout out at the end here to two other frameworks or approaches to therapy.

that have been extremely influential. The first is family systems therapy and systems thinking in general. And this is the idea that we are all parts of systems, big and small, in all these different ways in our lives. And it's very difficult to understand the individual without understanding the broader context that that individual exists inside of.

In family systems, this is taking that notion and applying it to a family. The idea being that families are complex and as the behavior of one individual changes, so do the behaviors of all other individuals inside of that system. And it's also been applied... more recently to more of a social justice framework, understanding people as part of broader communities that have problems, and therefore those problems can show up in the behavior of the individual in all of these different ways.

There are other approaches to therapy like internal family systems, which obviously draw heavily on family systems theory, and it applies it kind of more to the inner world, how we have all of these different parts or aspects. that, at least according to Dr. Richard Schwartz, are their own individuated selves and therefore have skin in the game in different kinds of ways and impact our behavior. Another approach that I want to name here is more...

integrative or holistic approaches, and particularly somatic approaches. These have really popped up as a major force more recently, but inside of them is often a a real referencing and acknowledgement of non-Western approaches to therapy that have existed for a very long time. So you can maybe see that as a kind of manifestation inside of that more Western medicalized model of all of these different...

forms of learning and information that we've had for long periods of time just based on the way that people interact with each other and what we find therapeutic in nature. And it really seeks to include often the body as a way in to

self-understanding, to treatment, to feeling better in the world, to learning about yourself. An example of this might be somatic experiencing from Peter Levine, who we're actually going to talk to again pretty soon on the podcast. I'm looking forward to that. Oh, awesome. Well, I'm really glad about that nod to family therapy and systems thinking, as well as to somatically oriented approaches of Virginia Satir, Jay Haley. Very, very useful.

And one of the things that also that came out of family therapy that I think is very useful for people is to realize that the person who might be the so-called IP, identified patient, In a family, like growing up, or in friend groups today, that person who's in that position and who might be the focal person for treatment.

is that way as an expression of the larger system. And may well, their so-called pathologies may serve functions in that system. And the system tends to maintain homeostasis, equilibrium. and tends to resist disruption and change. So one of the things that's often done in family therapy or other kinds of systemic approaches is to deliberately jiggle the systems.

disrupt them. And so you start breaking the scripts, essentially, that have tended to characterize them. So for a person, think about your role in your system. you know, growing up in your family of origin maybe, or think about your position in other kinds of systems, particularly with regard to the ways that it may not be so good for you.

in a system and ask yourself how you could disrupt the system so you can increasingly break out of it and then family therapy as you know really started to appreciate that the primary pathogenic factor of mental health is poverty yeah It's the systems in which we live and the throne as well. For people of color, women, people whose bodies do not fit the fashion magazine template.

You know, those systemic forces really make a big difference for people. A lot of the origin of what troubles people is outside their front door. And it's helpful to appreciate that. It's kind, it's compassionate, and it helps you also realize you are a globally good person. Who's dealing with a lot of shit that you shouldn't have to deal with. But you are. Here we are. We've got to do it anyways. Of course you're upset by it.

For real, for real, for real. I love that. And I think it's really great how as we've gone through this process, Dad, you've had those takeaways from each of them. which just like learning about and internalizing and doing a little process with can be therapeutic even as you're listening to this episode here. That's right.

I think that's a great template for something to learn from each of these many approaches. So something that you've mentioned a couple of times here, Dad, is coaching. To ask a slightly provocative question, so what's the difference between therapy and coaching? All right. So therapy is a protected word. Like I get to identify myself in California as a psychotherapist. Someone who is unlicensed as a psychotherapist is not allowed.

to use that word, nor related words like providing therapy. Even kind of in between words, like therapeutic, it's a little tricky. It's like for myself. I don't represent myself as offering medical treatment. I do not have a license as a physician. In that frame then, what therapists are doing in a medical model is treating pathology. A coach... is not licensed to treat pathology, mental pathology, just like I'm not licensed to treat physical pathology. Key difference.

Represent yourself as someone who's there to treat a psychiatric condition without a license to do so is a problem. Just like it would be a problem for me to say, I'm here to... you know, make the electrical wiring in your home really, really good, even though I don't have a license as an electrician or a contractor. So it's important to protect.

What people are doing, and that's why there are these regulatory bodies that regulate physicians or electricians or lawyers or therapists to make sure that they're not harming the consumer. You know, there's a place for that on the one hand. I think that's really true. On the other hand, as I've said, so much of what is involved for people in unhappiness or issues with other people.

or feeling bound up inside and blocked in moving forward in their life. So much of that is not a medical issue. And it's perfectly appropriate to address it through all kinds of other means. including through coaching, which has really come forward in ways that I think are fantastic to provide more opportunities for people to be supported, not just moving from minus 10 to zero. That's kind of the movement up through pathology. But moving from minus one or plus one...

up into the higher pluses of five, six, seven, eight, nine, and even 10. And that's where the territory of coaching is. Coaching is also very involved with dealing with practical problems. Like how can I move forward in my career? What would be maybe more skillful? ways to interact with another person? What are the things I can learn inside that would move me forward? A lot of very, very therapeutic conversations happen with coaches. And so I tend to be kind of loose about it all.

I think most coaches realize that if someone starts saying that they're experiencing hallucinations or paranoid delusions or they cannot stop washing their hands. Or they have a substance abuse problem that's just not going away. They're not able to really moderate it. You know, I think most coaches understand that at that point, the person they're dealing with needs a referral to somebody else.

I think that's a great quick summary of it here. Something that I do want to say that I think is an important point to reinforce part of what you're saying is that protected titles do not exist to serve the doctor or the therapist or the electrician. They exist to serve the consumer. These regulatory bodies are not regulating the consumers.

they are regulating the therapists okay so that's a really really important point here to understand if you work with a therapist in california you know for a fact that that person like an mft in california you know that that person has gone through 3,000 hours of supervised training. There is no standardization of the term coach. So what this means is there are many coaches who are phenomenal.

We've had a lot of people on the podcast who are coaches, who are phenomenal. I'm thinking right now of Brad, Brad Stolberg. He wrote Master of Change. He's an incredibly intelligent guy. He's done a ton of work. ton of personal work. He has deeply read on these topics. He would never describe himself as a therapist.

And he would also know, like you were saying, Dad, if somebody was like, hey, I'm having paranoid delusions, he would be like, look, not my framework here. But the work he's doing with people is awesome.

And so I just want to kind of reinforce that at the end here, that there are some differences here. And that's the real difference is what you know you're getting yourself into if you're working with a therapist. And so just with coaching, there's just more variation. There are people like Brad who are...

awesome and well-read and deep. And there are also a lot of random people who call themselves coaches who may or may not have ever done any training in order to earn that title because you just don't know. That's great. And you can find out. There are

certifications like the, I think, International Confederation of Coaches. Yeah, there totally are certification processes. Yeah, absolutely. Yeah. But the truth is, anyone can call themselves a coach. It is not a protected term. And so just keep your head on a swivel out there is all we're saying.

Yeah. That's good. I want to ask you a bunch of questions here at the end of the episode, Dad, that talks more about the specifics of doing therapy with people, what makes therapy work, finding a good therapist, all of that. I want to start by asking you, how long does it normally take for a therapy to work? Like, how long should somebody expect to work with a clinician? Great question. It depends to some extent on the scale and depth of the issue.

how big a deal it is. Absolutely. My own view about this is that in the first appointment, a person should feel understood. They should experience some clarity with their therapist about the nature of the issue they're working on. some understanding of the actions that are going to be taken to address that issue, and a general sense of what the path is from here. What's the prognosis and what's a reasonable course of treatment?

Like that is worth expecting out of your very first appointment. And if you're not getting that in your first appointment, particularly if you try to get it, that's a big orange flag. So, in other words, my view is you should already start to experience some benefit from the very first session. And if you don't, I would say that's a yellow flag. Certainly within the first few sessions.

you should start to experience some real benefit. If on the other hand, it feels like you're just orbiting the issue, your therapist is kind of asking you the same question. So how was your week? How did you feel? And so forth.

That's not very good. Now, sometimes it does take a little while to get a good history. History very often really matters. So sometimes, you know, the result of, let's say, for me like a second or third session is i'm starting to get a really pretty good history from somebody but i'm also making connections with them along the way between what has happened

and what happened to them and what they're feeling now so already those connections should be starting to give a sense of forward movement and i think sometimes people just drift along too long longer than they need to drift. Yeah. Another version of that drifting along is people who feel like they're being told either overtly or subtly by their therapist, just stick with it, just stick with it, it will eventually start working.

is there a period of time you think people should stick with it before deciding to try on somebody else good question again so what are they sticking with now if a person is needing to stick with, let's say, a really engaged homework each week in which they really are trying to budge their belief systems, cognitive therapy here. in serious ways. And let's say also they're really trying to stick with my focus. If I were to create a therapy, which I've thought about, I would call it resourcing.

And I would put a hyphen between the re and the sourcing because I'm an ultimately spiritual kind of guy interested in the deepest sources of all. You're laughing for us. You're just so unbelievably on brand here, Dad. I just can't even, I don't even have the language for it.

It's just so funny to me. It's nice to be recognized for being a really good person. But anyway. As we all are. As we all are. As you, the listener, are as well. That's right. Creating resources inside. So if that's what we're... trying to help the person stick with. It's appropriate for me as a therapist to really encourage them to stick with that. But if they stick with that, they really do stick with the mental practices.

They're working with their minds. After three weeks, certainly after a month or so, and they're not getting much benefit, and I know they're working hard, then I'm looking elsewhere. I'm looking particularly to their environment. Is it still banging on them? And also, could there be some biology that's getting in the way? But I can't get there unless they've actually stuck with it. And I think that a part of this is...

Just the classic, if all you have is a hammer, everything looks like a nail. There are clinicians who… are quite focused on a particular way of solving problems, a particular approach that they've specialized in, a particular way of being with their clients, a particular way they want the session to run, all of that kind of stuff.

A lot of the time for those people, particularly as people specialize more and more, you see more and more of this kind of an issue, everything gets back to the thing that they really know how to do. And sometimes that's because it really is a very good general purpose tool. Dad, I would say that a lot of your work gets back to the heal process. That is a very general purpose tool for working with the mind. There are a lot of tools that are not so general purpose.

And if your clinician is kind of pushing a tool on you all the time that you feel is just not really a great fit for you, I would say that after a couple of weeks, maybe a month at the upper limit of it, you feel like that tool's just... not really the tool for you, but you also feel like your clinician is pretty attached to that tool, man, I would really start looking elsewhere. Yeah, excellent point. Two other things here.

First, sometimes people come in the door, including because of insurance payments. And the client and I say, hey, we're going to do six sessions. We're going to do everything we can in these six sessions. And for that reason alone. you know that's how long we're going to stick with it yeah that's what we're doing here one of the benefits of that

relates to the classic line, the prospect of being hung in the morning concentrates a man's mind wonderfully. Yeah, I don't know. I'm curious about your take on this, Dad. I understand what we were talking about earlier with CBT and the problems of a prescriptive eight to ten.

week course of therapy. At the same time, a lot of situations where therapy just lingers and lingers and lingers and just kind of you're just paddling, but you're going nowhere. Yeah, exactly right. And I've known people and It could be, like there is, you may know, something called short-term dynamic psychotherapy. So they're really drawing on psychoanalytic approaches, but it's defined as...

very short term. There's even another therapy, I forget what the name of it is, that's a one-session therapy that basically is really zeroed in on we're going to do one session, which, by the way, addresses some of the costs. If you know that you're going to go in there for that one session and the clock turns on and you've got 50 minutes. You're doing two hours with somebody or 90 minutes with them maybe in that one session. Or 50. Or 50, sure. Yeah. Yep. It's game time. Game on. Boom.

Ball's in the air, time to play. No one's messing around. It really tends to focus people, client and therapist. I'm reading a book right now, which I totally love, would strongly recommend it. almost everybody. It's called A Matter of Death and Life. It's by Irv Yalom, great existential therapist. And a lot of the time, I don't know if this was just now that he's older or if this was always the way that he practiced.

He would have people come in for consultations with him for just one session because they're visiting from wherever they're visiting from. He's a well-known guy. They wanted to book a consultation with him. Okay, I've seen him once. That is it.

It is really remarkable, and part of this is because he's just a legendarily great clinician, but I think that this is possible for other people as well, how much mileage you can get out of a single session. Absolutely. Particularly when that session is focused on a specific…

topic or a specific pain point. You are walking in the door to solve a problem. And I think that under circumstances like that, you can be really surprised at how quickly you can move. Yeah, very, very good. The other thing I wanted to add… Which partly relates to my comment earlier that a lot of what brings people into a coach's office or certainly into a therapist's office is not really a medical issue. You know, the number one diagnosis.

actually I believe for insurance billing, is called adjustment disorder. It's a catch-all term for some kind of strong reaction to ordinary life situations. and it covers an awful lot of ground. So in that context, basically someone is there because they want to be more in touch with themselves. Maybe it's just... Somebody who's grappling with kind of vague background, blue mood and anxiety. They're in for the long conversation. I've had people who would come to me roughly once a month.

as almost like a check-in, because I was someone in their life with whom they could really unpack their life. I knew enough about it at this point, and I could help them think about it. orient around what was useful to do next right that kind of therapy can certainly extend over a long period of time but if someone is coming in you know with

specific issue, they want to make something different in their life, I'm zeroed in. And I think a good therapist would be zeroed in too. How can I help this person really get a lot of gain within a few months? Which, to your point that you mentioned earlier, also speaks to some of the issues with cost to people when they're considering the cost of therapy. Maybe they could do...

one session or two sessions, but the idea of doing like a long every week for a year is just like they're not even in the universe of being able to afford that. Again, you might be really surprised at what you can get out of just a couple of sessions. Just thinking about this. You know, this idea of, yeah, let's make some real progress in the next few months. My personal experience is that the individual who actually comes into the room for their first appointment, eager.

to make a lot of headway over the next several months, is in the minority. They tend to be fairly uncommon. Usually what happens is the person comes in, they're bothered by something, but really they're ambivalent about the changes inside. That would lead them to not be bothered by that or to progress in some way in an important area of typically love or work or both. And I'm saying this not to be defensive about...

my own failures to help people. And I'm not saying it as a kind of a cranky dad sort of thing. It's really as an opportunity. You know, if someone came in to improve their physical fitness and they got a trainer, they joined a gym, they really understand that if they want to get significant results in a few months, they've really got to bring themselves to it. They got to make the efforts.

There needs to be a continuity, a consistency of effort. People get that. And weirdly, it's almost like, what? With regard to their own minds, often. But the same is really true. Just like with your body in a gym or just like building an add-on to your garage, you realize, okay, you know, we really need to get at it if we want to see results in a few months. And I love clients like that.

Also, to be annoying here, very often, in my experience, the clients like that are the people you would almost kind of stereotypically least expect. commit to this with the culture of self-awareness and mindfulness and new age thinking and whatnot, but boy, they're eager to work.

Yeah, they got a problem and a place to be. Yeah, there's a humility to it and there's a straightforwardness to it. There's a kind of, dare I say it, working class ethic. They get at it. You know, and often the people that sort of drift tend to be the people who've... Been to a few therapists before me. They've read a few books. They've taken a few courses. They're okay, but they don't really grab hold and realize, wow, I need to do something different.

from how I've approached my mind in my past. I need to do something different here that's really engaged and has traction. In the past, on many previous episodes, Dad, you've mentioned there are some questions that every therapist should be able to answer. And if they can't, that's a definite red flag. What are some of those questions? Because you've never really mentioned them. You've just kind of alluded to them.

That's funny. Well, coming into the therapy, you have a nice list here of questions from the American Psychological Association that a prospective therapist should be prepared to answer. I will say, though, in the real world in which demand exceeds supply for affordable therapy, to have a therapist who would be willing to...

talk with you for an hour for free to answer some of these questions, you may not be able to find them. Uncommon. You might get a 15-minute free intake that's often offered, but that's about it.

Yeah, yeah. But in that context then, Forrest, do you want to read your well-prepared list from the APA? Oh, sure. Well, so these are just general ones from the APA. I'm actually way more interested in your vibey ones, Dad. Oh, then I'll go for it. Yeah, but so here are a couple just right off the bat, like questions you can think about.

asking a prospective therapist or clinician or even a coach you could do this with. This is actually a great question, I think, for people and it gets to concentrating the focus. I've been feeling fill in the blank and I'm having problems with fill in the blank. What experience do you have helping people with these types of problems? I think that's a great question. Another one you can ask about the therapist areas of expertise. Do you normally work with individuals or families?

Do you work with people who are more or less like me? What kind of treatments do you use? And have they been proven to be effective for different categories of people or for my particular problem or issue?

It would be hard to find somebody who would be like, no, my treatments have not been proven effective. But I think that what they're trying to do is kind of nudge people towards slightly more quote-unquote evidence-based or science-driven approaches, which I think in general is like a reasonable thing to do here.

Then obviously asking, what are your fees? And do you have a sliding scale fee policy? It can be a great question to ask people. And please do not feel uncomfortable asking a therapist, do you offer sliding scale fees? Like, ask it. Even if they don't list it, just ask it. It's okay. and then if it's relevant for you what type of insurance do you accept is a huge one to ask if you're trying to get more affordable care and do you accept assurance at all that's great okay so now for my my list of

what you should be able to ask your therapist. And I want to preface this by saying that I think a lot of people are uncomfortable prodding their therapist. Because it's so intimate and personal and kind of vulnerable, in a way they would feel comfortable prodding their electrician. Yo, electrician, the lights don't work.

Physician, I've been taking this pill for this ailment and my skin is still purple. It's not working. What's the plan, right? People feel much more forthright, I think, in raising those kind of questions with other categories of professionals. So with a therapist, it's very appropriate to ask, so what's your formulation of what we're working on here? How do you kind of sort out the elements to it?

How do you see them as fitting together? What's your take? What's your diagnosis, if there is one? What's your formulation of what we're trying to do? Second, what's your strategy? What's your plan? What are we trying to do to produce good change that lasts inside me? So second question, what's the strategy? What are we trying to do? Third.

How do you think it's going? Do you see progress? What do you think is getting better? And then the fourth question, very straightforward and practical, what do you think we should keep doing and what do you think we should change? Specifically, what do you think you should keep doing? What do you think you should change to get more results here? And what do you think I should do?

to get more results here? These are very straightforward, simple questions, but if your therapist just can't answer them, so what do you think is wrong with me, doc? What's your formulation? And they just can't give you a clear answer. Then they're kind of trying to play pin the tail on the donkey in the dark.

So they need to be able to have some kind of clarity about what's going on with my mind and what are we trying to accomplish there? And how are we trying to accomplish that? And is there anything we ought to do to do better? So to me, those are really fundamental and great. No, I think that's an awesome list, Dad. And maybe a part of that is it speaks to the relationship.

Do you feel like this is a person to whom you can ask those questions? Do you feel that particularly if you ask them in a remotely socially skillful or understanding or kind way, do you feel like they've received them well? Or do they receive them with a lot of defensiveness and a lot of concern about your role as the client in the process who is just supposed to sort of do what I tell you to do?

That, for me, would be a major red flag if I talked to a therapist and asked them those questions, and I felt like they were pretty defensive about it. I'm so glad we're talking about those. In a way, what I'm getting at is summarized in the word treatment. First of all, what's the treatment of the therapist in the sense of how are they treating you broadly? Do they treat you with respect and kindness and concern and interest? But beyond that, they're there to treat something.

to fix something, to change something for the better. And I think that a lot of people, a lot of therapists, frankly, just have this belief. It's almost like a... kind of a faith tradition in therapy, that somehow if we just get together and we talk, and I, the therapist, am a warm, accepting, benevolent person, and if we just do that. that somehow that will be transformative for people. Yeah, it'll all just kind of work itself out. Yeah. And the thing about Carl Rogers, for example...

is that he himself was an incredibly soulful, deep, and wise person. So he wasn't just mirroring back to people what they were saying. You know, he was... asking questions or restating things in ways that kept drawing people more and more deeply into what was really true for them in a context in which they could really unpack what was true for them. So he was treating.

their depression, their shame, their inner conflicts, let's say. He was actually treating that in a way that was very gentle, but without a doubt. He was getting down to the bottom of things in ways that were actually transformative for people, including really affirming their beautifulness and wonderfulness already, right? And so you have the right.

unless you just want to be there and just check in with your therapist weekly or monthly, and you don't have somebody who knows you well you can talk with, great, great. But if you're there, to accomplish something in your mind you want to feel that your therapist is really engaged in trying to accomplish that that's treatment inside of that point are so many different

what we might call green flags and red flags that a person could have when working with therapists, just that fundamental position that you're speaking to, so many other things flow from naturally. For me, a lot of this does come back to the nature of the relationship between the client and the clinician, and I think that you kind of have a vibe pretty quickly and pretty early in the process, at least speaking for myself. If we get to the end of the second session and I just feel like...

we're not connecting in a human way, I'm probably not going to keep on working with that person. It just suggests that there's not a great fit between the two of us. So we've mentioned a bunch of things like that. One of the things I want to ask you about, Dad, were there any... commonalities between the clients that you felt that you struggled to help? Well, severity of issues. They had a lot of issues.

it was very understandable that they were as distressed and dysfunctional as they were. And also sometimes they were grappling with ongoing conditions that were really hard for them. So that would be a commonality among people who maybe got less from it. There were a handful of people I found hard to like, and I would refer them on because I think that one thing you're looking for is a therapist who likes you. Now, maybe...

Your therapist is annoyed by you occasionally, but on the whole, they like you. As humans are, it's okay. Yeah, they find things to like about you, and they rest in that genuine human kind of friendliness, fondness. goodwill towards you that's really important you want to feel that i think clients who would not get out of their head to put it a certain way despite my best efforts get out of their story

or their beliefs were just a very detached relationship with their interior, those people, there just wasn't that much traction. You know, there wasn't that much that was juicy. If in the therapy conversation, It's juicy. It's emotional. It's consequential. The person is talking about things that really matter. Okay. You're probably going to get some forward movement, right?

On the other hand, if the conversation is desultory, if it's about, you know, what they did this week or repetitive statements about what they think about certain things or how they still feel certain ways about certain things. then it is not very juicy. It's not very alive. And the therapist themselves, one of the clues for me was if when the therapeutic process is going awry is that I would start to space out.

not pay close attention a little bit. I tend to be really attentive, so I'm pretty good that way. But that was a clue to me. If I felt the energy, the air was being sucked out of the room, I could just tell we're swerving away from something important. What are we swerving away from, right? And so people I couldn't stop swerving. Those were harder to work with. I would say the last is that I'm not deeply trained in somatic, emotionally expressive.

treatments like Reichen therapy or sensory motor experiencing or somatic experiencing, sensory motor approaches and so forth. I've experienced a ton of them. I relate to them myself, but I'm not particularly trained in them. The kind of clients who really needed that approach, I would then tend to refer on to other people. Yeah. The clients who, on the other hand, like I am, could hear the words and immediately access an experience related to the words.

and then were good at working in their own interior, and then I could be a very skillful guide to the maze of the mind. That was the kind of client I would do the best with. So we've talked about a lot during this episode today. We've covered a whole bunch of ground. It's a little bit of a longer one. I do want to ask you here, Dad, at the very end of this.

Is there anything else that you want to say about this topic or anything else that you feel like we haven't covered yet that you want to throw a bone to? Well, first off, and I hope you will edit out. my kind of long-winded responses to certain things, probably because this is so close to my work. You know, I started doing therapy with people as a hotline counselor at UCLA back in 1971 or 72. That's a while ago. And then in the human potential world, yeah, I was having a lot of very...

therapeutic conversations with people before I got licensed. So this is a long journey for me, plus my adulthood has tracked. just as you pointed out, a lot of the major movements and developments in psychotherapy over the course of my own life. Something to say maybe at the end here just really quickly is a thing to appreciate is how new

therapy is as a discipline in terms of the westernized approach to it that often, as we've said several times, exists inside of that more medical model. This is a young field. depending on how you want to count, about 150 years old would be, I would say, the furthest back you could go and reasonably call it Western psychotherapy. You could go back to some of the philosophical traditions that have existed in the West before then and pull in some of that.

In terms of the medical model, about 150 years at max. That is a young discipline. And you've been around for about a third of it, Dad, in terms of your engagement with it. Pretty wild. Yeah, just about. Okay, so finishing notes. I've been reflecting a lot about what produces good change that lasts. And as you know, related to my focus on resourcing yourself, the internalization.

of experiences of what you want to grow inside is absolutely fundamental. That's that second step of learning. We start by experiencing. but then we help what we're experiencing to sink in and change our bodies, particularly leave lasting changes in the brain. That's a fundamental matter. And to the degree that that is not happening in a therapy.

It will not be productive. But the degree to which it is happening, including between sessions, then a person will experience a growth curve or a healing curve, an improvement. So attention. Therefore, to the connection between states and traits is really important. What I mean by that is that it's so easy in a therapeutic conversation to be having experiences after another.

that are not scraping the bottom. What I mean by that, they're not creating change deep down inside. And so I think it's really important to pay close attention. to the linkages between what people are thinking or feeling or saying and what is actually shifting deep down inside.

So to the extent that the therapist is paying attention to that and the client is paying attention to that, then I think you can get some real mojo. You can get some real change. And the other thing I would want to say is that... The essence of therapy is the essence of any deep, meaningful conversation. And humans have had those conversations for 300,000 years at least as anatomically modern humans and probably before that.

with our hominid ancestors who could also use language, certainly to some extent. If we were more able to sit around the fire at night with our friends and just talk about life and how it is, I think there'd be less need, you know, for therapists, let's say. deep down it's natural to have a meaningful, exploratory, courageous conversation with someone who cares about you.

So you want to be with someone who cares about you and is prepared to have that deep, courageous, meaningful, consequential, impactful conversation with you. And to keep leaning in to... What matters? What are the takeaways? What's going to have lasting value? And it could be the lasting value for you is the sense of your therapist as a being. That was my primary takeaway.

from one of my two therapies the more conventional one the other one was a kind of jungian dream analysis with a pretty wild guy but very that the sense of unconditional positive regard that fearless inquiry into my interior That was my primary takeaway from that therapy, but it made a big difference for me. So the point is, whatever it is that's going to make a big difference for you, valuing it and opening into it and letting it really land in you.

To me, that's one of the very most important things. I really love this, Dad. I thought this was a great conversation. I'm really glad we did it. So thanks for taking the time. I really enjoyed today's conversation with Rick, which I thought was a fantastic primer for anyone who's interested in learning more about therapy, understanding the process of therapy better or going to therapy themselves.

And I started by asking Rick what he thought some of the biggest factors were that led to a course of therapy going well for somebody, drawing on his many, many years of experience working with people. And he mentioned a number of different factors. He talked, for instance, about the environment that the person was in, the depth of the issue that they were facing.

And also their individual motivation, motivation, motivation, motivation, as he said, is what it really comes down to. Even a fantastic therapist. can't overcome an unmotivated client, but a motivated client can get really far even with a mediocre therapist. And then he named several other factors that tend to really matter. First, what's the level of functioning of the therapist? Is this an engaged, interested, proficient, soulful, feeling person that you're dealing with?

Or is it somebody who's just kind of clocking the time here? Then based on the combination of the motivation of the client and the level of functioning of the therapist, something might emerge that's often referred to as a strong therapeutic alliance. And this is just the sense of fit between client and clinician. Then something that Rick emphasized that I thought was really interesting was avoiding superficiality in the work that's being done.

Are you just kind of operating at this superficial layer of, okay, I'm thinking this, and I'm doing that, and we're going to do a little tinkering around with these things? Or are you really getting down to the underlying processes of change that allow us to internalize whatever's going on inside of the room where the work is being done and extrapolate that out to the actual process of our daily life?

We then talked about why therapeutic modality is not on that list of things that are really important to a course of therapy, and how most of the time for most reasonably well-researched approaches to therapy, what research has found is that they're approximately as good as each other on average over large samples of people. Some might be particularly more well suited for certain issues, while others might be particularly good for certain clients.

You as somebody listening to this might really mesh very well with one approach to therapy, while another person might really not mesh well with that approach to therapy. But that's where the variation really is, as opposed to being able to say, one of these approaches to therapy is just better than another.

I then gave a little monologue on the cost of therapy, how cost is a major issue, and some lower cost options that a person might consider exploring. These could be things like clinics or... working with an associate therapist, finding therapists who do more sliding scale work, although that is unfortunately quite uncommon, or finding therapists who work with your insurance provider, which unfortunately is also quite uncommon.

Another way to approach this issue that we talked about at some length later on in the conversation is entering the therapy with a distinct focus and a clear maximum number of sessions. You might be somebody who could really afford... one or two or three sessions of therapy with a very very good clinician. But you're totally spooked by the notion of this being a reoccurring payment in your life that goes on for months and months and months, which is how many people approach therapy.

You do not have to do long-term therapy to get a ton of value out of therapy. And a lot of people are really surprised by the value that they're able to get out of just a couple of sessions if they are a focused, motivated client. with a real point of emphasis in the work that they want to do with that clinician. Then we spent a lot of time talking about the many different schools of therapy. We boiled it down to five major schools with a couple of acknowledgments for other schools as well.

And I really loved how Rick emphasized a specific piece of learning that you could pull from each of these different approaches. I will not be summarizing that whole part of the conversation. It would take way too long. But the schools that we talked about were psychodynamic or psychoanalysis-based approaches to therapy, behavioral therapy, humanistic psychology. cognitive therapy, and mindfulness-based or what are also referred to as third-wave behavioral approaches to therapy.

We also gave some big shout-outs to other approaches to therapy like family systems therapy and systems thinking in general, and then also more integrative, holistic, and often somatic approaches that have become more popular recently. From there, I asked Rick a somewhat provocative question about the difference between therapy and coaching. If you're listening to this or watching a video, if you're watching on YouTube.

You've probably bumped into coaching in the past, and you might be wondering, hey, how's that distinct from therapy? To quickly summarize that, therapy is a pathology-driven model. It is an attempt to solve a medical problem. The basic medical model of therapy is you're trying to take somebody from a minus 6 to a minus 2 or a 0 or, hey, maybe a plus 2.

Now because I could just hear like thousands of people listening to this right now going, wait, wait, wait, that's not what I do as a therapist. There are many, many approaches to therapy that are not about that at all. They are much more about exploring. the upper reaches of human functioning, becoming a happier and more skillful person in the world. That's a ton of the work that Rick does, but the basic medical model is about pathology. Coaching is often more focused

on improving performance for somebody who is already in the minus 2 to plus 2 part of the range, okay? And then taking that person up to more of a plus 5, 6, or 7. That's the more thematic difference between the two groups. The functional difference is that coaching is not a protected term. Therapist is. If you work with, say, a LPCC or an MFT or a PhD,

in clinical psychology, something like that. You know that that person has gone through a standardized education where they have had to learn a lot of different stuff, and they have many, many, many hours of practice doing this thing. If you work with a coach, you do not know that. There are certification programs for coaches, and so you can do some research to try to figure out is this a legit person or not, but there is no standardization of coaching.

It's just really important to understand that. And standardized terminology and protected terms exist to protect the consumer, not to protect the therapist. And you are just not covered by those protections if you work with somebody who is operating under a term that isn't a protected term. In the back half of the conversation, I asked Rick a whole bunch of different questions about the process of therapy.

what tends to lead to it going well, questions you can ask your clinician, things like that. And I started by asking him, is there amount of time that it takes therapy to work? That was a pretty complicated question. We talked about it for a while. The upshot of it is that... If you have two sessions and you're not really feeling it, that's a big yellow flag. If you work with somebody for a month and you don't really feel like you're getting anywhere, that's probably a red flag.

Now there are exceptions to this. There are approaches to therapy that take a longer time to work for a bunch of different reasons. It could be because you're dealing with a very complex problem that has a lot of pieces associated with it. But if you feel like you've truly received no value from the approach whatsoever, and particularly if you feel that and you also don't feel that connected to your clinician, well, that's a sign that maybe it's time to start looking elsewhere.

I then mentioned how in the past Rick has alluded to a bunch of questions anyone should be able to ask their clinician that the clinician should be able to answer and in the past on the podcast he's never actually named what those questions were and so I asked him about it during this episode and he said

three things to boil it down first what's the issue that we're trying to address here second what kind of an approach are we going to take to solve that problem what are the tools that we're using and then third what can we change about what we've been doing up until now? What are ways that I can change that'll improve treatment? And hey, what are ways that you can change that'll improve treatment? Now those can be provocative questions.

It can be a little uncomfortable to ask them. And it's understandable if a clinician is put, you know, a little bit on the back foot by them. But if you ask them in a kind manner and you feel like your clinician is either totally unable to answer them, or very defensive in the process of doing so, well, that's probably at least a yellow, if not altogether a red flag. At the very end of the conversation, I asked Rick if there was anything that he felt

that we had left out, or anything he just wanted to say to leave people with. And I thought it was really interesting how he emphasized the importance of moving from state to trade. Are we helping things sink in? Are we taking what we're doing inside of the room and moving it outside of the room? That is the whole goal of therapy. And particularly, how is your clinician attending to that process?

I thought this was a great conversation. It ran a little longer, but that was because we were just talking about a really big topic for this one. I'm very interested in feedback about it. Would you be interested in more episodes like this? Do you want to hear more about the process of therapy? kind of enough. If you could, leave a comment down below if you're watching on YouTube, or maybe a rating and a positive review on somewhere like Spotify or iTunes. Those really help us out.

And for just a couple of dollars a month... you can support the show and receive a bunch of bonuses in return until next time thanks for listening and I'll talk to you soon